A Review of CLL Chemotherapy Approaches

Published on
February 1, 2016

Topics include:
Treatment

Is chemo still a
valid form of treatment for CLL? Which
patients benefit most from this course of treatment? Patient Power founder Andrew Schorr asks Dr.
Nicole Lamanna to explain the various therapeutic agents currently in use, who
they are for and why. Dr. Lamanna gives
both biological and historical background for agents such as chlorambucil,
steroids and FCR versus (F)BR.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

But we’re talking about the chemotherapy
agents. So I've had fludarabine
(Fludara), and I've had another one of course that gets thrown in there,
cyclophosphamide (Cytoxan). But tell us,
these are some of the drugs we’ve had for many years, now, and some are still
used, right?

Dr.
Lamanna:

Yes. So chlorambucil (Leukeran) was actually our
oldest oral therapy, and now we talk about all these oral therapies. But if you
want to think about it, chlorambucil was our oldest oral therapy. It’s an oral alkylating treatment, and it’s
something that certainly has less toxicity than some of our intravenous
chemotherapy agents, let’s say compared to fludarabine. But now it’s been reinvigorated with the combination
of combining that with some of the monoclonal antibody treatments. So it’s approved for older patients who may
have other comorbidities or other medical conditions where more aggressive
therapies may be too toxic.

And so you can combine that with some of the monoclonal
antibodies and achieve some nice responses and certainly improve some of the
symptoms and cytopenias that people have.
And it’s commonly more used in Europe than it is here in the United
States. But certainly there’s still a
proportion of folks who receive this agent.

Andrew
Schorr:

So just so I understand, there’s still a place
for it, but you're looking at it now in combination with newer medicines.

Dr.
Lamanna:

Yes.

Andrew
Schorr:

Okay. And
prednisone (Deltasone) not used much by itself, really?

Dr.
Lamanna:

No, not typically used by itself. With the maybe exception of some of the
autoimmune cytopenias. So sometimes it’s
used for patients. There’s a sidebar in
addition to the CLL, again due to your immune system, you can also develop what
they call autoimmune hemolytic anemia or thrombocytopenia. In other words, that you can actually attack– you can make antibodies that might
attack your red cells. A little bit of a
different mechanism than what Michael was referring to when the CLL crowds out
the bone marrow and makes your other blood counts low.

This is actually—your bone marrow actually makes your counts
fine. But when it leaves and goes into
the circulation, you're actually attacking that cell line. And so you can have a reduced hemoglobin or
reduced platelet count because you're attacking that cell. And so sometimes corticosteroids are very
effective in that usage. It can often be
combined with other therapies.

So sometimes we’ll use steroids and monoclonal antibodies together. Steroids can, again, be part of other chemo
immunotherapy programs. So it’s usually
used in combination.

Andrew
Schorr:

I had FCR, fludarabine, cyclophosphamide and
rituximab (Rituxan). Probably again, if
we could take a look, it’s become the world standard. It was invented here, proliferated—just show
your hands if you’ve had FCR. Just a few
people. Okay, not too many. But if we did it around the world, now, there
would be a lot of people. But another
combination in the R, we’ll talk about rituximab, or a monoclonal antibody,
rituxan. And some people have had BR,
bendamustine rituximab. Anybody have
that? BR? Nobody here but it is used in some other
places.

Dr.
Keating:

Like New York.

Andrew
Schorr:

In New York, you use it?

Dr. Lamanna:

Why did you want me to say that?

Dr.
Keating:

I just got you excited.

Dr.
Lamanna:

I've used all, haven’t I?

Dr.
Keating:

Yes.

Dr.
Lamanna:

I ran a sequential FBR program. All right.
So you know, clearly there’s been a dichotomy a little bit about the
more aggressive chemotherapy programs, and FCR traditionally has been used for
younger, fitter patients. Bendamustine
(Treanda) and rituximab really was an Eastern European regimen, actually
started in the lymphoma setting and then moved its way into CLL and into the
United States.

And there was a randomized trial showing that it’s
efficacious as well as a front-line therapy program. We can argue whether or not we think it’s
more or less efficacious than FCR, maybe a little less toxicity. And so bendamustine-rituximab has become a
very common front-line regimen for older, fitter patients and perhaps even
younger, fitter patients.

Many of us, depending upon again—those of us who are
obviously looking at trying to change the paradigm of the disease and improve
upon it would alllove for folks
like these to continue on clinical trials.
But certainly these are the most common that we see in the community
being given is bendamustine-rituximab-fludarabine based therapy.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.